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Ann Thorac Surg 2000;70:960-961
© 2000 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, University of Miami and the, Jackson Memorial Hospital, Miami, FL, 33136 USA
Invited commentary
This report by McMullan and coworkers deals with two important aspects of cardiac surgery, namely, major cardiac operations and reoperations and the use of partial left ventriculectomy in a Jehovah’s witness in desperate need of surgical treatment for end-stage heart disease. Major cardiac surgery in Jehovah’s witnesses carries a major risk related to the fact that, due to religious belief, these patients refuse transfusion in the face of catastrophic hemorrhage. For this reason, some surgeons are hestitant to perform major cardiac procedures in Jehovah’s witnesses. Many cardiac centers do not perform cardiac transplantation in such patients, especially those institutions whose volume of cardiac transplantation procedures is small. Furthermore, reoperations in Jehovah’s witnesses carry an even higher risk of hemorrhage. Therefore, surgery has to be carried out with great care and has to be justified by unequivocal indications.
One of the most serious operations in cardiac surgery is partial left ventriculectomy. The risk of catastrophic hemorrhage from the suture line, which is one of the major complication, may require immediate transfusion and reoperation, with large amount of blood loss. The authors not only performed partial left ventriculectomy in one of these patients, but when the mitral valve repair failed, the patient was offered and was reoperated upon for mitral valve replacement and redo-partial left ventriculectomy. These are heroic measures, and the surgeons should be commended for dealing with such a difficult problem in a patient with desperate need of cardiac surgery. The decision to perform a partial left ventriculectomy may be justified, in light of the fact that a donor heart was not immediately available, as the patient was rapidly deteriorating.
Although results of partial left ventriculectomy have not been uniformly positive, and the majority of surgeons have abandoned this procedure, some patients, for unknown reasons, benefit from this operation. This patient went from NYHA Class II/IV to Class I after partial left ventriculectomy, with EF improving from 20% to 27%. Unfortunately, surgeons have not been able to predict which patients will fair well. The issue of mitral valve repair and the extent of left ventricular resection have been discussed before [1]. These patients do not tolerate mitral insufficiency postoperatively and the group from Buffalo [1], after a rather trying period, elected to replace the mitral valve, so that a larger amount of left ventricular muscle could be resected. Also, the surgeon was assured of a competent mitral valve. A case report like this one from McMullan and colleagues deserves careful evaluation and scrutiny.
References
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